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Health Questionnaire Form

Download Health Questionnaire Form

Health & Fitness Pre-Screening Questionnaire

Please take a few minutes to answer the following questions.

 

Name

Date of Birth

Phone

Email

FITNESS INFORMATION:

Are you currently exercising?

YES
NO

Type of exercise?

Frequency of exercise?

What do you wish to achieve with your new program? Please list your goals:

How many times per week will you be undertaking your new fitness program?

MEDICAL INFORMATION:

Are you currently seeing a medical practitioner for any injuries or illness?

Do you have any current medical conditions?

YES
NO

If YES, please specify

In the past 6-12 months, have you undergone any surgical procedures? Please specify.

Do you have a family history of heart disease?

YES
NO

Have you ever suffered from a heart condition?

YES
NO

Have you ever suffered from any of the following?

Chest Pain
Shortness of breath from exertion
Chest Tightness
Heartburn

Do you have high blood cholesterol?

YES
NO

Do you have any type of diabetes?

YES
NO

Do you have a pace maker? Please comment:

Do you take any prescribed medication? If Yes, What type and why?

Do you take any nutritional supplements? If yes, What type and why?

Is there a family history of prostate cancer, breast cancer or colon cancer? Please Specify

Do you have or have you ever had any of the following conditions: (Please Tick)

High blood pressure
Glandular Fever
Stroke
Dizziness
Asthma
Lung Disease
Gout
Sinus Problems
Heart murmur
Stomach Ulcer
Diabetes
Arthritis
Epilepsy
Drug or Alcohol Problems
Chrone's Disease
Depression
Recent weight gain/loss
Thyroid Problems

Any other symptoms or conditions that concern you?

Have you ever suffered from de-hydration that has had to be treated?

YES
NO

Do you smoke?

YES
NO

How many per day?

Are you pregnant now or have you recently been pregnant?

YES
NO

Do you have any muscular injuries or pain? Please specify

Have you ever suffered from de-hydration that has had to be treated?

YES
NO

Back:

Ankles:

Neck:

Elbows:

Knees:

Hips:

Shoulders:

Other:

Do you suffer from arthritis?

YES
NO

Do you suffer from osteoporosis

YES
NO

On a scale of 1-10 (1 = no stress, 10= overwhelming stress), how would you rate your current stress levels?

WORK

1
2
3
4
5
6
7
8
9
10

PERSONAL

1
2
3
4
5
6
7
8
9
10

Do you have any reason why you should not exercise in a program?

DUTY OF DISCLOSURE:

Before participating in the Healthy for Life Program, you must disclose any injuries or medical conditions that may be affected by participating in this program.

The tests you are about to undertake are for screening purposes only and are not a diagnosis of a condition / illness; if any findings are outside the normal ranges you may be referred to your Doctor for assessment.

RELEASE FROM LIABILITY:

If you have indicated in your medical information any areas for concern in relation to your exercise program I/we may request that you receive medical clearance prior to undertaking your program.

Should you suffer any injury, illness or condition that may affect your ability to exercise I/we would request that you advise us immediately.

Should you have any questions regarding your program I/we request that you discuss these issues with your health and fitness professional.

STATEMENT:

I recognize that the instructor is not able to provide me with medical advice with regard to my medical fitness and that this information is used as guidance to the limitations of my ability to exercise. I have answered the above questions to the best of my ability in a truthful manner and understand the above information. By signing this document I do not hold either the health and fitness professional or CFA responsible for any injuries that may occur when I exercise.

CONFIDENTIALITY & PRIVACY RIGHTS:

Protecting your privacy and your personal information is an important aspect of the way CFA creates, organizes and implements our activities.
We will only collect personal information from you with your prior knowledge and consent.

Collection of this personal information is not required by law; however failure to provide some of this information might result in you being ineligible to participate in this program.

We will only use this personal information provided by you for the purposes by which it was collected. We will not disclose your personal information without your consent unless disclosure is required or sanctioned by law.

If you wish to update or amend the information stored by CFA please contact the Healthy for Life Program Leader who will be responsible for the storage and accuracy of this data.

We have implemented rules and measures to protect the personal information that we have under our control form: unauthorized access, improper use, alteration, unlawful or accidental destruction and accidental loss. We will remove personal information from our system where it is no longer required (except where archiving is required).

If you have any questions or concerns, please refer to the relevant CFA policies or contact the Healthy for Life Program Leader or the CFA Privacy Officer.

Printed Name

Signed

Date

Health and Fitness Professional